家庭血压监测的临床应用

血压测量是诊断高血压病的基本手段,目前主要有三种方法评价血压：诊所偶测血压、动态血压监测和家庭血压监测。家庭血压监测方便、经济,已有大量数据表明：与诊所偶测血压相比,家庭血压监测是评估心血管疾病风险的一个更好的预测因子。同时它能改善高血压患者的治疗依从性,有利于血压控制,监测降压药物疗效,减少医疗费用。另外对鉴别白大衣高血压和隐性高血压也很有帮助。     

Home Blood Pressure Monitoring in Clinical Practice: A Review

Home blood pressure monitoring is a convenient and inexpensive technique to monitor blood pressure in hypertensive patients. There are convincing data that home blood pressure monitoring is a good predictor of future cardiovascular risk, perhaps better than office blood pressure. Home blood pressure measurement can be standardized using validated instruments and systematic protocols; normative criteria have established home blood pressure >135/85 mm Hg as hypertensive. Home blood pressure monitoring has been shown to improve compliance and blood pressure control, and to reduce health care costs. Ongoing studies are evaluating management of hypertension based on home blood pressure readings compared with traditional office-based readings. Home blood pressure monitoring is particularly useful for evaluation of white coat hypertension and masked hypertension. In this article, we discuss the methodology for measuring blood pressure at home, its comparison to the other measurement techniques, the advantages and disadvantages, cost benefit analyses, and ongoing clinical trials to help define the role of home blood pressure monitoring in the clinical management of hypertension.     

Implementation of Home Blood Pressure Monitoring in Clinical Practice

To investigate the implementation of home blood pressure monitoring (HBPM) guidelines, a phone survey was performed in 366 primary care physicians (PCPs). Of the PCPs, 90% routinely used HBPM for white-coat hypertension, treatment titration, and diagnosis. Thirty percent trusted HBPM more than office measurements. Reported drawbacks were questionable reliability of patients’ reports and devices inaccuracy. Thirty-one percent advised patients on device selection, 38% were aware of validated devices, and 69% reviewed (not averaged) the readings. Seventy-nine percent used higher than recommended threshold for hypertension diagnosis. Although PCPs routinely use HBPM, there are important gaps in their knowledge and educational activities are required.     

High Blood Pressure in Children: Clinical and Health Policy Implications

J Clin Hypertens (Greenwich). Hypertension is a global problem, affecting both developed and developing nations. In addition to being a major cause of morbidity and mortality, hypertension places a heavy burden on health care systems, families, and society as a whole. Despite evidence of an increasing prevalence of hypertension among youth, the consequences of early onset are poorly established and often overlooked. Childhood hypertension is often asymptomatic and easily missed, even by health professionals. Target organ damage is detectable in children and adolescents, however, and hypertension continues into adulthood. Additional strategies to improve cardiovascular health among children and adolescents are needed, including methods to achieve healthy lifestyles at home and in school, improved systems for diagnosis, and research on mechanisms and timing of interventions. The burden of hypertension in the young will continue to grow unless it is given the attention it deserves by policy makers, health care providers, schools, parents, and society. This report aims to increase awareness of the problem of hypertension in childhood. Recent reports on prevalence and target organ injury are discussed and health policy initiatives to improve blood pressure control are proposed.     

Evolution of Blood Pressure Clinical Practice Guidelines: A Personal Perspective

Before the second half of the 20th century, most clinical decision making was based on expert opinion. By the 1960s, experience in actuarial and research cohort studies had provided strong evidence that blood pressure was an important risk factor for cardiovascular disease. The landmark 1967 and 1970 Veterans Administration Cooperative Study trials confirmed the value of antihypertensive drug therapy in preventing stroke, myocardial infarction, and heart failure in adults with high levels of diastolic blood pressure. They also provided an impetus to develop the first blood-pressure–related clinical practice guideline in 1977. In subsequent years, more structured and comprehensive blood-pressure guidelines have evolved to become a major resource in clinical and public health practice. Despite some limitations, these guidelines provide useful evidence-based guidance for diagnosis and management of high blood pressure. The core advice in most of the current comprehensive blood pressure guidelines is more similar than different. Modelling studies suggest that better adherence to guideline recommendations would result in a lower average blood pressure and substantial improvement in public health.     

The Role of Ambulatory Blood Pressure Monitoring in Clinical Practice

The introduction of noninvasive techniques for the repetitive measurement of blood pressure in ambulant subjects has permitted improved precision in the assessment of hypertension during normal daily life. The traditional clinic (or “office”) method of blood pressure measurement has the advantages of simplicity and low cost, and forms the basis of the current operational definitions of hypertension, but it is limited by the normal variability of blood pressure and the “white coat effect.” By contrast, ambulatory blood pressure provides information on circadian variations in blood pressure and alterations due to changes in behavior, and may, therefore, be more appropriate for diagnosing hypertension. However, it is important to note that the values used to define normotension and hypertension for clinic blood pressure are not appropriate for ambulatory blood pressure. Recent population studies have proposed that the upper limit for 24-h ambulatory pressure should be 119 to 126/75 to 80 mm Hg, and failure to recognize this may account for at least some cases of “white-coat hypertension.” There is increasing evidence that ambulatory blood pressure is more effective than clinic blood pressure in predicting the organ damage associated with hypertension, whereas data from intervention studies indicate that a reduction in ambulatory pressure is correlated with a reduction in left ventricular (LV) mass. Finally, ambulatory blood pressure measurements may provide a number of advantages in the development of antihypertensive therapies: by permitting better identification of trough and peak effects, by confirming that the efficacy of formulations for once-daily dosing is maintained throughout the 24-h period, and by minimizing the placebo effect.     

Racial Differences in Blood Pressure Control: Potential Explanatory Factors

Summary Objective The objective of the study was to identify potential explanatory factors for racial differences in blood pressure (BP) control. Design The design of the study was a cross-sectional study Patients/Participants The study included 608 patients with hypertension who were either African American (50%) or white (50%) and who received primary care in Durham, NC. Measurements and Main Results Baseline data were obtained from the Take Control of Your Blood pressure study and included clinical, demographic, and psychosocial variables potentially related to clinic BP measures. African Americans were more likely than whites to have inadequate baseline clinic BP control as defined as greater than or equal to 140/90 mmHg (49% versus 34%; unadjusted odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3–2.5). Among factors that may explain this disparity, being older, reporting hypertension medication nonadherence, reporting a hypertension diagnosis for more than 5 years, reporting high levels of stress, being worried about hypertension, and reporting an increased number of medication side effects were related to inadequate BP control. In adjusted analyses, African Americans continue to have poor BP control relative to whites; the magnitude of the association was reduced (OR = 1.5; 95% CI 1.0–2.1). Medication nonadherence, worries about hypertension, and older age (>70) continued to be related to poor BP control. Conclusions In this sample of hypertensive patients, there were a number of factors associated with poor BP control that partially explained the observed racial disparity in hypertension control including age, medication nonadherence, and worry about BP. Medication nonadherence is of particular interest because it is a potentially modifiable factor that might be used to reduce the racial disparity in BP control.     

ASH Position Paper: Dietary Approaches to Lower Blood Pressure

A substantial body of evidence has implicated several aspects of diet in the pathogenesis of elevated blood pressure (BP). Well-established risk factors for elevated BP include excess salt intake, low potassium intake, excess weight, high alcohol consumption, and suboptimal dietary pattern. African Americans are especially sensitive to the BP-raising effects of excess salt intake, insufficient potassium intake, and suboptimal diet. In this setting, dietary changes have the potential to substantially reduce racial disparities in BP and its consequences. In view of the age-related rise in BP in both children and adults, the direct, progressive relationship of BP with cardiovascular-renal diseases throughout the usual range of BP, and the worldwide epidemic of BP-related disease, efforts to reduce BP in nonhypertensive as well as hypertensive individuals are warranted. In nonhypertensives, dietary changes can lower BP and delay, if not prevent, hypertension. In uncomplicated stage I hypertension, dietary changes serve as initial treatment before drug therapy. In hypertensive individuals already on drug therapy, lifestyle modifications can further lower BP. The current challenge is designing and implementing effective clinical and public health interventions that lead to sustained dietary changes among individuals and more broadly in the general population.     

高血压合并糖尿病患者52例临床治疗分析

目的分析苯磺酸左旋氨氯地平联合厄贝沙坦对高血压合并糖尿病的治疗效果。方法该研究选取2012年7月—2014年6月52例高血压合并糖尿病患者为对象,随机分成两组。对照组患者接受苯磺酸左旋氨氯地平片治疗,实验组患者接受苯磺酸左旋氨氯地平联合厄贝沙坦治疗。连续用药12周,对比分析两组患者治疗前后收缩压(SBP)、舒张压(DBP)、胰岛素抵抗指数(HOMA-IR)的变化和不良反应的差异。结果采用t检验分析进行数据统计,治疗后患者SBP、DBP、HOMAIR均明显下降,其中实验组各指标下降幅度明显大于对照组,差异有统计学意义(P0.05)。采用χ2检验分析进行数据统计,两组治疗期间不良反应发生率差异无统计学意义(P0.05)。结论采用苯磺酸左旋氨氯地平联合厄贝沙坦治疗高血压合并糖尿病,可有效控制血压,改善胰岛素抵抗,将其作为高血压合并糖尿病治疗的有效方案推广应用。     

急性卒中的血压管理

急性卒中的血压波动较大,血压水平与卒中患者预后相关。文章对急性卒中血压的变化及其机制、目前有关血压调控存在的争议以及治疗所遵循的原则进行了阐述。     

Treatment of High Blood Pressure in Germany

The reunification of Germany has made it possible to compare the health care in two independently developed social structures. The prevalence of hypertension was considerably greater in East German men and women, compared with West German men and women, although salt intake was lower in East Germany than in West Germany. Cardiovascular mortality was correspondingly greater. A centralized public health effort was used in East Germany, whereas in West Germany, the activities were decentralized and to a large extent dependent on private philanthropists. In the last two decades, cardiovascular mortality declined in West German men and women, whereas the same was not true for East German men and women. Hypertension incidence, awareness, treatment, and control have improved slightly in Germany, but not enough to explain the improved morbidity figures. Twenty percent of men and women remain unaware of their hypertension, 40% are aware but not treated, and only half are aware and controlled. Complacency is unjustified in Germany and much needs to be done.     

Rationale for Triple‐Combination Therapy for Management of High Blood Pressure

J Clin Hypertens (Greenwich).The goals of antihypertensive therapy include optimal reduction in blood pressure (BP) while providing a favorable tolerability profile that promotes long‐term adherence to treatment. For most patients with hypertension, these treatment goals cannot be achieved with monotherapy. When instituted early, however, combination therapy results in more rapid control of BP. This approach may facilitate improvements in long‐term clinical outcomes, compared with more traditional and time‐consuming stepped care and add‐on algorithms for the management of hypertension. This review summarizes the rationale behind combination therapy, specifically triple‐combination therapy, and discusses which combinations are most likely to result in better BP control, fewer side effects, and reduced risk of target organ damage. Supporting evidence from recent triple‐combination therapy trials also is included in the review. Finally, the role of single‐pill (fixed‐dose) combination therapy in enhancing patient adherence is also discussed. J Clin Hypertens (Greenwich). 2010;12:869–878.

Results from placebo‐controlled clinical trials have firmly established that reducing blood pressure (BP) in patients with hypertension significantly reduces the risk of cardiovascular (CV) events. ^{1 , 2 , 3 , 4} In a meta‐analysis of randomized trials, antihypertensive therapy reduced the risk of stroke by 35% to 40%, the risk of myocardial infarction by 20% to 25%, and the risk of heart failure by >50%. ³ Using data from the National Health and Nutrition Examination Survey Epidemiologic Follow‐Up Study, Ogden and colleagues ⁴ determined that a sustained reduction of 10 mm Hg in systolic BP (SBP) over 10 years in patients with stage 1 hypertension and additional CV risk factors would prevent 1 death for every 11 patients treated.The results of epidemiologic studies and landmark clinical trials have been incorporated into evidence‐based guidelines for the treatment of hypertension. ^{5 , 6 , 7} These guidelines recommend that management of hypertension should be based on the severity of BP elevation and on the presence of other CV risk factors and comorbidities. In all cases, these guidelines stress that BP should be reduced to <140/90 mm Hg in patients with uncomplicated hypertension and to <130/80 mm Hg in those with diabetes or chronic kidney disease (CKD). More recent recommendations have included patients with established vascular disease and heart failure in the groups requiring the lower BP targets. ⁸ Despite the availability of many effective antihypertensive agents, achieving these BP targets is difficult in many patients. BP is inadequately controlled in one third to one half of patients receiving treatment for hypertension in the United States and Canada and in 40% to 66% of patients with concurrent hypertension and diabetes. ^{9 , 10 , 11 , 12 , 13} In the European Union, BP is inadequately controlled in more than two thirds of treated patients. ^{13 , 14} The reasons for inadequate control of BP include the multifactorial nature of hypertension, the presence of concurrent medical conditions, and/or resistant hypertension from secondary causes. Other factors include inconsistent patient adherence and the reluctance of physicians to increase therapy in response to inadequate BP control (therapeutic inertia). Another important reason is an over‐reliance on monotherapy, which effectively controls BP in only 20% to 30% of the hypertensive population. ^{15 , 16} The focus of this article is to review the rationale for combination therapy, specifically triple‐combination therapy, and assess which combinations are most likely to result in better BP control, fewer side effects, and reduced risk of target organ damage. The results from recent triple‐combination therapy trials will be reviewed. The role of single‐pill (fixed‐dose) combination therapy to enhance patient adherence is also discussed.     

Simultaneous Compared With Sequential Blood Pressure Measurement Results in Smaller Inter‐Arm Blood Pressure Differences

There are currently few recommendations on how to assess inter‐arm blood pressure (BP) differences. The authors compared simultaneous with sequential measurement on mean BP, inter‐arm BP differences, and within‐visit reproducibility in 240 patients stratified according to age (<50 or ≥60 years) and BP (<140/90 mm Hg or ≥140/90 mm Hg). Three simultaneous and three sequential BP measurements were taken in each patient. Starting measurement type and starting arm for sequential measurements were randomized. Mean BP and inter‐arm BP differences of the first pair and reproducibility of inter‐arm BP differences of the first and second pair were compared between both methods. Mean systolic BP was 1.3±7.5 mm Hg lower during sequential compared with simultaneous measurement (P<.01). However, the first sequential measurement was on average higher than the second, suggesting an order effect. Absolute systolic inter‐arm BP differences were smaller on simultaneous (6.2±6.7/3.3±3.5 mm Hg) compared with sequential BP measurement (7.8±7.3/4.6±5.6 mm Hg, P<.01 for both). Within‐visit reproducibility was identical (both r=0.60). Simultaneous measurement of BP at both arms reduces order effects and results in smaller inter‐arm BP differences, thereby potentially reducing unnecessary referral and diagnostic procedures.     

Prediction of Stable High Blood Pressure in Adolescents

We studied the relative importance of the initial BP and associated factors in adolescents to predict stable high BP. Out of 17.634 children aged 12-13 yrs an upper group the upper 5% of the distribution curves for both SBP and DBP/ a lower group/10% random from the remainder/were yearly fallowed for 4 yrs/boys: 1680, girls: 1643/. About 2/3 of children remained at the same percentile point: < 30% and ≥ 70% of SBP and half of them of DBP distribution. Significant positive tracking correlations were found both for SBP and DBP between the initial BP and follow-up BP readings in the same individual. Stepwise regression analysis showed that the SBP taken at the fourth follow-up can be explained by 29% in boys, 24% in girls on the basis of screening SBP and by 47% in boys, 42% in girls on the basis of SBP measured at the four previous examinations. Using discriminant analysis, 6-9 variables out of 18 studied could correctly allocate adolescents with stable SBP or DBP/< 70% or ≥70% at least 3 examinations/. Our study shows the importance of initial BP and a number of factors associated with stable high BP.     

Home Blood Pressure Monitoring: Primary Role in Hypertension Management

Two main sleep disturbances, namely obstructive sleep apnea (OSA) and sleep deprivation, have gained growing interest in the field of hypertension research. This fact is supported not only by evidence that both disturbances are quite common in modern societies but also that OSA and sleep deprivation are associated with several pathways that may contribute to a predisposition to hypertension or even exacerbate blood pressure levels in hypertensive patients. In the present review, we will discuss current evidence supporting a potential role of these sleep disturbances in the resistant hypertension scenario.